DOCUMENT #1  -  Reopening Applications on Rejected Claims

	Management Update Insurance Services: Claims Administration & Self Insurance
Effective Date 01/17/2006    Topics Order & Notices Reopening   Issuing Authority Sandy Dziedzic Cheri Ward Jean Vanek	REOPENING APPLICATIONS RECEIVED ON REJECTED CLAIMS A new order has been developed to respond to a Reopening Application received on a claim where the rejection order has become final and binding. Effective January 17, 2006, adjudicators will issue an order with the following language when this situation occurs. “The Department of Labor & Industries received an application to reopen this claim. The department’s record shows that this claim was rejected on DD/MM/YYYY. The rejection of the claim is final and binding. The department is unable to consider the reopening request.” State Fund adjudicators – Use the automated order titled DS – Reopening Denied - Rejected Claim on the MAIL system, which includes the above language.   Self Insurance adjudicators - Use the SI automated DS order and include paragraph #54A.

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DOCUMENT #2  -  When the 90 Day Clock Begins On a Wrong Claim

Memo
	To:	Claims Management Staff
	From:	Jody Moran, Program Manager for Claims Administration
	Date:	October 26, 1999
	Re:	The Ninety-Day Clock when an Application to Reopen is received on the Wrong Claim

 

The purpose of this memorandum is to provide adjudicators direction when an application to reopen is received on the wrong claim.

 

When a reopening application is filed under the wrong claim number the application is denied pursuant to Policy 16.20.  A letter is sent to the worker and attending physician, with a copy to the employer, advising that reopening will be considered under the proper claim number.  The ninety-day clock for acting on the application under the correct claim number begins with the date that the reopening denial order was issued under the incorrect claim number.  In the even that reopening is granted under the second claim, the effective date of reopening can be no earlier than 60 days before the receipt of the first reopening application.

 

EXCEPTION: When a reopening application is filed under a claim for the wrong injured worker, no denial order is issued.  A letter is sent to the worker and attending physician, with a copy to the employer, advising that reopening will be considered under the proper claim number.

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DOCUMENT #3  -  Medical Reports Received After Claim Closure is Final

 

Memo
	To:	Claims Management Staff
	From:	Jody Moran, Program Manager for Claims Administration
	Date:	October 26, 1999
	Re:	Medical Reports Received After Claim Closure is Final

 

The purpose of this memorandum is to clarify the actions adjudicators should take when medical reports are received after a claim closure becomes final.

 

If the department receives medical information on a closed claim (final and binding), the claim should be reassigned to a WCA 3.  The WCA 3 will send a letter to the injured worker and the attending physician, with a copy to the employer, requesting that a reopening application be completed and returned to the department for consideration of reopening of the claim.  The WCA 3 should enter an appropriate tickle date with a notation to deny reopening if the information is not received.  If the required information or a letter from the worker is not received within 60 days after the date of the request for a reopening application, the WCA 3 issues an order denying the reopening of the claim.  A manual denial order containing the following language is used to deny reopening.

No application for Reopening has been made to the department by the injured worker as required by law.

The WCA 3 enters the date of the order in LINIIS in the reopening denied date field.  If a letter or completed application is received from the injured worker, the reopening is considered on its merits with the date the letter or application is received entered in LINIIS as the reopening application received date.

 

If, within 60 days following an order denying reopening for the reason that no application was received, the department receives a reopening application or a letter from the injured worker we review and address the denial order within 90 days.  The previous denial order is corrected and superseded when a new decision is made.

If the decision is to reopen the claim, the adjudicator may establish the effective date of reopening no more than 60 days before the receipt of the first medical report. 

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DOCUMENTS #4 & #5  -  90 Day Time Limit to Reopen & Criteria to Reopen

Review Department of Labor & Industries Policy #16.31 (effective 10/1/1995) regarding the 90-day Time Limit to Act on Re-opening Applications in your Policy Manual.

Review Department of Labor & Industries Policy #16.20 (effective 12/6/1990) regarding the Criteria for Re-opening claims in your Policy Manual.

 

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DOCUMENT #6  -  Loss of Earning Power and Reopenings

	Management Update Insurance Services: Claims Administration & Self Insurance
Effective Date 07/22/2007   Topic LEP     Issuing Authority Sandy Dziedzic Cheri Ward Jean Vanek	LEP and REOPENINGS RCW 51.32.090 is revised effective July 22, 2007. The new subsection (3)(c) states: The prior closure of the claim or receipt of permanent partial disability payments shall not affect the rate at which the Loss of Earning Power benefits are calculated upon reopening the claim. For all reopening applications received on or after July 22, 2007, loss of earning power (LEP) benefits will be paid based on a comparison of current earnings to the updated wages from the job at the time of the original injury. Reopening a claim and the previous payment of permanent partial disability benefits is no longer a factor in how LEP benefits are calculated.   Do not refer to Policy 5.81, point 10, Task 5.81-A, or the Davis vs. Bendix decision. Follow the RCW when paying LEP benefits.   NOTE:  This is an interim policy change.  This issue has been referred to the policy committee to be included in upcoming revisions

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DOCUMENT #7  -  No Reopenings for Additional PPD Only

July 7, 2002
TO:	Claims Management Staff
	Policy & Quality Coordination Staff
	Claims Consultant Staff
FROM:	Jody Moran, Program Manager, Claims Administration
	Vickie Kennedy, Program Manager, Policy & Quality Coordination
	George Pickett, Program Manger, Self Insurance
	Craig Lowe, Claims Appeals Manager, Legal Services
SUBJECT:	Application of RCW 51.32.160, WAC 296-14-400 Claims cannot be reopened solely for the award of permanent partial impairment.

 

This statute outlines the department’s obligation when an application for aggravation of disability (reopening application) is received.  This memo is not a change in existing policy.  The purpose of this memo is to clarify existing policy.

 

In order to reopen a claim, a worker must prove that his or her condition has been aggravated since the date of last claim closure or reopening denial.  Aggravation is the worsening of the condition caused by the industrial injury or occupational disease.  Such worsening must be based on objective medical findings and must have occurred since the claim was last closed or ordered to remain closed.

 

A claim should not be reopened solely for the award of permanent partial impairment (PPD).  If the claim was previously closed without an award for PPD, and that closure is final, the claim cannot be reopened to award such impairment.  This holds true even if there was some indication of permanent partial impairment in the claim file prior to closure and adjudicative misjudgment or error caused the claim to be closed without such award.  All parties had a right to protest or appeal the order closing the claim without PPD.  Again, a claim can only be reopened where there is objective medical evidence of worsening.  Please see Claims Administration Policy 16.20.

 

If a reopening application is received and there is objective evidence of worsening (with or without an increase in the permanent partial disability level at the time of the application), the claim can be reopened.  This reopening can result in additional time-loss compensation and other appropriate benefits, in addition to medical treatment.  (If this is an over-7 reopening, please refer to Policy 16.40.)  Once reopened, the claim can be closed with the appropriate award for permanent partial impairment.  There does not have to be an increase in the impairment level from the prior closure for this award to be made.

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DOCUMENT #8  -  Examples to Determine the 7 Year Time Limit

Attachment 16.20-A  -  Examples of Determining the Seven-Year Time Limit

Effective Date:

3/15/99

 

First closing orders became final prior to July 1, 1981
1.	First Claim Closure	June 1, 1979	W/O Medical
	Claim Reopened	May 1, 1987
	Second Claim Closure	May 1, 1988	With Medical
The seven year reopening limitation has run on this claim because the first closure was prior to July 1, 1981. Because the closure was prior to July 1, 1981, it does not matter whether the claim was closed with or without medical documentation.   First closing orders issued between July 1, 1981 and July 1, 1985 are deemed closed and final on July 1, 1985 for purposes of reopening.
2.	First Claim Closure	August 2, 1981	With Medical
	Claim Reopened	September 10, 1983
	Second Claim Closure	December 1, 1984	W/O Medical
The claim is considered closed as of July 1, 1985. The seven-year reopening limitation begins to run on July 1, 1985 because the first closure with medical documentation falls between July 1, 1981 and July 1, 1985.
3.	First Claim Closure	August 2, 1981	W/O Medical
	Claim Reopened	September 10, 1983
	Second Closure	December 1, 1984	With Medical
	Reopened	September 7, 1985
	Third Closure	November 7, 1987	With Medical
The claim is considered closed as of July 1, 1985. The seven-year reopening limitation begins to run on July 1, 1985 because the first closure with medical documentation falls between July 1, 1981 and July 1, 1985.
4.	First Claim Closure	August 2, 1981	With Medical
	Reopened	September 10, 1983
	Second Closure	December 1, 1984	W/O Medical
	Reopened	September 2, 1985
	Third Closure	December 1, 1987	With Medical
The claim is considered closed as of July 1, 1985. The seven-year reopening limitation begins to run on July 1, 1985 because the first closure with medical documentation falls between July 1, 1981 and July 1, 1985.

 

5.	First Claim Closure	August 2, 1981		Non-compensable, W/O Medical
	Reopened	September 2, 1983
	Second Closure	December 1, 1984		With Examination
The claim is considered closed as of July 1, 1985. The seven-year reopening limitation begins to run on July 1, 1985 because the first closure with medical documentation falls between July 1, 1981 and July 1, 1985.
6.	First Claim Closure	August 1, 1981		Non-compensable, W/O Medical
	Reopening	September 1, 1983
	Second Claim Closure	December 1, 1984		W/O Medical
The claim is considered closed as of July 1, 1985 for purposes of adjudication, but, the seven-year reopening limitation does not begin to run until a closure is based upon medical documentation.   Reopening denial with medical documentation
7.	First Claim Closure	August 1, 1981		W/O Medical
	Reopening Denial	May 1, 1984		With Medical
The claim is considered closed as of July 1, 1985. The seven-year reopening limitation begins to run on July 1, 1985 because the reopening denial with medical documentation falls between July 1, 1981 and July 1, 1985.
8.	First Claim Closure	May 2, 1981		With Medical
	Appealed to Superior Court
	Final Decision Upholding	July 2, 1983
The claim is considered closed as of July 1, 1985. The seven-year reopening limitation begins to run on July 1, 1985.
9.	First Claim Closure	May 2, 1981		With Medical
	Appealed to Superior Court
	Final Decision Upholding
	Closure	August 1, 1985
The seven-year reopening limitation begins to run as of August 1, 1985.

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DOCUMENT #9  -  Payment of Provisional Time Loss on Reopenings

POLICY 16.35
Section:	Aggravation and Reopening	Effective:	9/1/98
Title:	Policy 16.35 - Paying Provisional Time-loss Compensation on Reopening Applications	Cancels:	Policy 16.35 dated 12-6-90
See Also:	RCW 51.32.210 (claims acted upon promptly)
	RCW 51.32.240 (payments made in error)
	WAC 296-14-400 (reopening for benefits)
	Policy 5.91 (voluntary retirement)
	Policy 16.20 (criteria for reopening)
	Policy 16.40 (reopening over seven year)
	WCA Manual, Appendix E
Approved by:
	Ron Gray for the Insurance Services Policy Council

 

 

This policy applies to reopening applications received on or after December 6, 1990, regardless of the date of injury, except for reopening applications received on claims closed over seven years. (See Policy 16.40 for reopening claims closed over seven years.)

 

1.           Adjudicator pays provisional TLC on certain reopenings.

 

In order to pay provisional time-loss compensation (TLC), the adjudicator must review the reopening application to determine if it contains specific criteria for contention and certification:

 

Contention:

       The worker must not be working.

       The worker must not be retired.

       The worker must not be receiving TLC under another claim.

       The condition that is keeping the worker from working must be an accepted condition.

       The worker must not be kept on salary by any employer.

(To avoid duplicate benefits, provisional TLC is not paid if the worker was kept on salary. However, if the claim is reopened and the employer is not the same as on the date of injury, the worker is entitled to TLC for the period that she or he was kept on salary.)

 

Certification:

       The attending physician must indicate that the reason for the worker's inability to work is an accepted medical condition.

       Measurable (objective) findings must support the worker's inability to work.

 

2.           Adjudicator must make first payment within 14 days.

 

The adjudicator must pay provisional TLC on reopening applications within 14 days after receiving sufficient medical verification. The adjudicator determines what is sufficient medical verification. (See RCW 51.32.210.)

 

3.           Adjudicator does not pay provisional TLC for dates prior to receipt of the reopening application.

 

The adjudicator must not pay provisional TLC for days prior to the date the department receives the reopening application. If the adjudicator reopens the claim, he or she may pay TLC for days prior to the date the department received the reopening application.

 

If the date of disability is later than the received date on the reopening application, the adjudicator pays provisional TLC from the date of disability.

 

4.           Adjudicator pays provisional TLC only for accepted conditions.

 

The adjudicator pays provisional TLC only for disability due to the accepted conditions and not for new conditions after the claim was closed.

 

5.           When appropriate, the State Fund adjudicator issues an interlocutory Order terminating TLC.

 

When the worker returns to work or is released for work prior to the reopening determination, the State Fund adjudicator shall issue an interlocutory Order terminating provisional TLC. (See Task 16.35-A.)

 

6.           State Fund adjudicator issues a separate determinative Order for a reopening.

 

When approving a reopening application, the State Fund adjudicator must not use a payment narrative on a TLC Order. The adjudicator must issue a separate determinative Order. (See Worker’s Compensation Adjudicator Manual, Appendix E for sample of the Reopening Order and Reopening for Treatment and Close Order.)

 

 7.          Adjudicator must assess an overpayment in certain situations.

 

When the adjudicator has paid provisional TLC and then denies a reopening application, the State Fund adjudicator must assess an overpayment. The adjudicator issues one determinative Order that terminates provisional TLC, denies the reopening, and assesses an overpayment. For self-insured claims, the adjudicator only issues an overpayment if requested by the self-insurer.

 

Policy author:	Mary Burbage, (360) 902-6904
For technical questions:	State Fund Claims Training, (360) 902-4576
	Self-Insurance Claims Training, (360) 902-6904

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DOCUMENT #10  -  Over Seven Year Reopenings

 

POLICY 16.40